Journal Article > Study

The authors tested the efficacy of using a verbal checklist to prepare anesthesiologists to give general anesthesia for cesarean delivery. Most participants found the checklist to be useful, and the authors conclude that the tool could improve patient safety.

Journal Article > Study

The authors analyzed surgical adverse events to assess the occurrence, cause, patient impact, and preventability of the incidents. They found that the surgical events increased average lengths of stay by 9.9 days and have a lower level of preventability than other types of adverse events.

Based on a recommended clinical indicator in surgical patients, this study used a cohort of more than 44,000 to identify 200 patients who experienced an unplanned postoperative admission to an intensive care unit. Investigators discovered that more than half of these patients experienced at least one incident or near miss and that their mortality rates and lengths of stay were significantly increased, while their likelihood for discharge was decreased. The authors conclude that this methodology may serve as an important tool to promote patient safety by generating data that do not require complex risk-adjustment models and rely on more easily obtainable information from a medical chart.

Book/Report

East Perth, WA, Australia: Department of Health of Western Australia; 2006.

This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.

Journal Article > Study

This cohort study, conducted in an Australian hospital, reports on the implementation of an incident reporting system within an existing anesthesia electronic medical record. Anesthesiologists were required to document any adverse events, in one of 16 predefined categories, as part of their routine clinical documentation. Acceptance of the system was high, and the vast majority of reported adverse events were confirmed by chart review. As prior research has shown that incident reporting systems suffer from low physician reporting rates, integration of incident reporting into routine electronic documentation may help increase physician reports of errors.

This simulation study evaluated the performance of a novel advanced auditory display of a patient's vital signs. Participants using the auditory display were better able to detect potential patient safety events.

Tools/Toolkit > Multi-use Website

Geneva, Switzerland: WHO World Alliance for Patient Safety; June 25, 2008.

This initiative provides a surgical safety checklist and related educational and training materials to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization's checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.

Journal Article > Commentary

Many health care systems have applied crew resource management methods originally developed by the aviation industry in an effort to develop high-reliability organizations. This article highlights the differences between the aviation and health care operating environments and points out the risks of adopting non–evidence-based safety interventions.

Journal Article > Study

This study used a simulated operating theater to evaluate anesthesiologists' error rates when faced with distractions during a clinical emergency. The authors advocate for using this research design to evaluate the effect of safety measures.

Journal Article > Study

The so-called July phenomenon, in which errors are supposedly more common in July due to an influx of inexperienced residents and students, has long been a source of gallows humor in hospitals. Although prior studies have reached mixed conclusions, this Australian study of anesthesia errors did find a significant increase in preventable adverse events for procedures performed by trainees during the first 4 months of the academic year. Interestingly, error rates were higher for trainees at all levels, not just first-year residents. This finding implies that underlying systems issues as well as clinical inexperience resulted in adverse events. An accompanying editorial calls for revising training models in order to provide adequate supervision and support for new trainees. A case of inadvertent hypoglycemia resulting from an intern's lack of familiarity with insulin ordering at his new hospital is discussed in an AHRQ WebM&M commentary.

This qualitative study used interviews with operating room personnel to identify aspects of interpersonal relationships and organizational culture that affect teamwork and communication during surgical procedures.

Journal Article > Review

This review highlights the many potential communication gaps created by having patients traverse multiple settings, disciplines, and providers—all mediated through different documents and documentation practices—in the perioperative setting.

Journal Article > Study

This survey found that anesthesiologists minimized the impact of attitudinal and emotional barriers on reporting unspecified adverse events, except for concerns about being blamed by colleagues. For specified events, the influence of perceived barriers was dependent on whether an error actually occurred.